EXECUTIVE SUMMARY

Case managers working together across the care continuum can improve the problem of healthcare silos.

  • Providers, as well as patients, need to learn more about the care continuum and case management’s role in it.
  • Case managers in primary care settings can help identify patient trends that might prevent a health crisis.
  • Case managers should keep in mind who they’re working with, including being aware of their client population’s cultural issues, and address needs through that filter.

Once a patient is hospitalized, the patient and family often become lost in the maze of healthcare, feeling a loss of control and unable to understand what’s going on with their medical treatment and insurance. Case managers working together from the hospital and community can help them navigate this maze more efficiently and with less stress.

“It’s very important for case managers in hospitals to not only do discharge planning, but to also get involved in the patient’s community so they can help that community provide the patient with the necessary support,” says Susan Rogers, RN-BC, MSN, CCM, a board-certified nurse case manager and chief executive officer of Rogers Professional Guidance Nurses in Overland Park, KS. Rogers speaks at national conferences about how case managers can build care management across the care continuum.

“We’ve always talked about healthcare having silos, including the silo of the hospital and primary care, and we as case managers have perpetuated that silo — even amongst ourselves,” Rogers says. “When you talk about hospitals and accountable care organizations [ACOs] and health plans, we are all the same regardless of where we practice.”

Increasingly, case managers are embedded in primary care sites, a trend that further emphasizes the need for the care continuum, she notes.

If every case manager — no matter where he or she works — advocated for patients, there should be no silos, Rogers says.

Rogers offers the following suggestions on building a continuum of care between case managers in various settings:

Educate providers about the care continuum. When working with hospitals and primary care providers, Rogers begins with education about case management. Case managers in primary care settings are in a good position to prevent health crises among at-risk populations, she notes.

They might identify trends in patients, such as elevated blood sugar levels that indicate pre-diabetes.

“The case manager in the primary care office is looking to find records and results to help people through health issues,” Rogers says.

Case managers also can help make sure that when patients are sent to a specialist or hospitalized that information from those handoffs returns to the primary care practice, she adds.

“Often, the primary care physician doesn’t know they’ve been in the hospital and there’s no communication until discharge,” Rogers says.

Continuous communication between case managers and care settings is a critical step in individuals’ wellness, she adds.

“Look at the community as a whole without the competition and old processes that go with it,” she suggests.

Risk stratify and assess patient issues. “If we look at the community as a whole, we might say we have 100 people with a [particular] diagnosis, and 20 might end up in the hospital; another 20 will need to see a specialist,” Rogers says. “So where do we need to divide our time?”

The answer might be to identify the higher-risk cases to pay more attention to them and prevent some of those people from returning to the hospital. Also, case managers can work with other community resources to find solutions to problems that result in patients’ worsening health and need for referrals beyond primary care.

“We need to figure out how to get back to the sense of community in healthcare,” Rogers says. “It’s very important that case managers keep in mind who they’re working for and that they identify their community.”

For instance, a case manager who works in a community that has a significant population of Vietnamese-speaking individuals might need to identify interpreters to work with primary care providers, Rogers says.

Case managers working with this sort of population might also need to think about the various factors, including cultural differences, that affect clients’ needs, she notes.

“Case managers need to be in the same thinking mode as their clients, or they’ll be ineffective in motivating them to make changes,” Rogers says.

For instance, Rogers’ own experience included working with a population of clients who lived in homes with dirt floors and outhouses. Helping someone with a mobility issue improve their independence under such circumstances is challenging, but the situation is made worse if the case manager doesn’t even know that’s how the client lives, she explains.

“If you know your population, then you can anticipate their needs,” Rogers adds.